Go with the flow

Question 1

What is renal/ureteric colic?

Answer 1

Renal or ureteric colic generally describes an acute and severe loin pain caused when a urinary stone moves from the kidney or obstructs the flow of urine through the ureter.

Question 2

When does renal/ureteric colic usually occur?

Answer 2

Very common - 12% of men and 6% of women will have one episode of renal colic at some stage in their life.
Incidence peaking between 40–60 years for men and in the late 20s for women.

Question 3

What investigations would you perform in the presentation of renal/ureteric coli?

Answer 3

Mid-stream specimen of urine: culture and measurement of serum urea, electrolytes, creatinine and calcium levels. 
Plain abdominal X-ray (kidneys, ureters and bladder): could show radiopaque stone in the line of the renal tract. 
Unenhanced helical (spiral) CT:  best diagnostic test available. 
Take a detailed history: could uncover possible causal factors e.g. vit D consumption (leading to hypercalcaemia), gouty arthritis, recurrent UTIs or intestinal resection.

Question 4

What is the treatment for renal/ureteric colic?

Answer 4

Strong analgesic delivered via IV infusion
If no sepsis, patient can be managed at home, small ureteric stones will pass spontaneously
Extracorporeal shock wave lithotripsy (ESWL) will fragment most stones which will then pass spontaneously.
Ureteroscopy with a YAG laser is used for bigger stones
Open surgery is rarely used

Question 5

What is the function of the prostate?

Answer 5

Secrete prostatic fluid, a component of seminal fluid. Secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate. This allows the semen to remain in a fluid state, moving throughout the female reproductive tract for potential fertilisation. Muscles of prostate gland help propel seminal fluid into urethra during ejaculation.

Question 6

Who experiences BPH?

Answer 6

Most common cause of urinary symptoms in men as they get older
3% men aged 40-50
Up to 25% men age 80.
Histological evidence in 90% men age 80.

Question 7

What is the pathophysiology BPH?

Answer 7

BPH is caused by increased cell number as opposed to increased cell size. Growth occurs as benign nodular or diffuse proliferation of muscular fibrous and glandular layers of prostate. Occurs in inner (transitional) zone (around urethra) in BPH and in peripheral layer in prostate carcinoma.

Question 8

What are the symptoms of BPH?

Answer 8

Weak urine flow, need to urinate more frequently, difficulty emptying the bladder, difficulty in starting to urinate, post-micturition dribbling, leaking urine, blood in the urine, bladder stones, UTIs.

Question 9

What causes BPH?

Answer 9

The causes for prostate enlargement are unknown. It’s linked to hormonal changes (oestrogen and progesterone) as a man gets older, mainly over 50 which will induce androgen receptors in prostate and stimulate hyperplasia.

Question 10

What are the risk factors of BPH?

Answer 10

Risk factors: age, obesity, diabetes, family history.

Question 11

What are the investigations performed for BPH?

Answer 11

Investigations: history-taking, bladder diary, urine dipstick test to rule out infection, U&Es, PSA test, digital rectal examination (feeling prostate through the wall of the rectum), transrectal ultrasound, biopsy.

Question 12

How to manage BPH through lifestyle changes?

Answer 12

Less alcohol, caffeine, artificial sweeteners and fizzy drinks, drink less in the evening, double voiding (urinate, wait, urinate), check medicines, keep a healthy weight, eat more fruit and fibre.

Question 13

How to manage BPH through medicines?

Answer 13

Alpha-blockers e.g. Tamsulosin, doxazosin
Relax the muscles in the prostate and around the opening of the bladder, making it easier to urinate. Help to relieve symptoms.
5-alpha-reductase inhibitors e.g. Finasteride
Slowly shrink the prostate so that it stops pressing on the urethra, making it easier to urinate. They can shrink the prostate by around a quarter after 6 to 12 months of treatment.

Question 14

How to manage BPH through surgery?

Answer 14

Transurethral resection of the prostate (TURP): remove the parts of the prostate that are compressing the urethra
Holmium laser enucleation of the prostate (HoLEP): removal using a high power laser
Transurethral vaporisation of the prostate (TUVP): Electric current is passed into a small roller ball or a mushroom-shaped electrode. This heats up and destroys the prostate tissue blocking the urethra.
GreenLight™ laser surgery
Prostatic urethral lift (UroLift®): sutures that hold prostate tissue away from the urethra, relieving the pressure
Bladder neck incision: involves cutting through the neck of your bladder to allow you to pass urine more easily
Open simple prostatectomy.

Question 15

How to differentiate between BPH, prostate cancer and prostatitis using investigations?

Answer 15

BPH - normal PSA, normal urine dipstick, enlarged smooth and rubbery prostate in DRE
Prostate cancer - high PSA, normal urine dipstick, enlarged, hard and nodular prostate in DRE
Prostatitis - normal PSA, abnormal urine dipstick indicating an infection, enlarged and painful prostate in DRE

Question 16

What is the PSA test?

Answer 16

PSA (prostate specific antigen): a protein produced by normal, as well as malignant, cells of the prostate gland.
Many men over 50 consider a PSA test to detect prostate cancer.

Question 17

How accurate is the PSA test?

Answer 17

The test is not very accurate, and we can’t say that those having the test will live longer.
Most men with prostate cancer die from an unrelated cause.
The test is falsely positive, may needlessly have more tests, eg prostate sampling via the back passage. May be worried needlessly if later tests clear.

Giving a one-off PSA test to men without symptoms doesn’t save lives from prostate cancer, because it picks up cancers that are unlikely to cause a person any harm, Misses cancers that are aggressive and probably would benefit from treatment.

Question 18

What are the treatment options for prostate cancer?

Answer 18

• Watchful waiting or active surveillance - suitable for older men, or men with significant comorbidities or slowly progressing tumours.
• Radical prostatectomy - remove the whole prostate gland through open, laparoscopic or robot assisted surgery. Risks include urinary incontinence, erectile dysfunction and incomplete resection of the tumour. Appropriate for localised prostate cancer, biochemical relapse after radical radiotherapy, locally advanced prostate cancer.
• External beam radiotherapy - directs an external source of radiation at the tumour from outside the body. Risks include bowel and bladder problems, erectile dysfunction and urinary problems. Appropriate for low and high risk localised prostate cancer, biochemical relapse after radical prostatectomy or patients with locally advanced disease.
• Brachytherapy - the radioactive source is implanted in the prostate with radioactive seeds or passed through catheters. Risks include alteration in urinary and bowel function and erectile dysfunction. Appropriate for localised prostate cancer and locally advanced prostate cancer.
• High intensity focussed ultrasound - uses ultrasound waves to heat the prostate gland and destroy the tissue. Risks include erectile dysfunction, urinary incontinence and rectal damage. Only used in clinical trials.
• Cryotherapy - used to destroy the prostate by freezing. Risks include erectile dysfunction, urinary incontinence and rectal damage. Only used in clinical trials.

Question 19

How can hormone treatment be used for prostate cancer?

Answer 19

Hormone treatment can be given as neoadjuvant (beforehand) or concurrent (at the same time) therapy. Risks include erectile dysfunction, loss of libido, breast swelling, hot flushes and osteoporosis. Appropriate for localised prostate cancer, biochemical relapse after radical prostatectomy or radiotherapy, locally advanced prostate cancer, metastatic prostate cancer.
Types:
- Androgen withdrawal – Surgery or medical, with luteinizing hormone releasing hormone (LHRH) agonists or antagonists.
- Androgen blockade – With drugs that bind to and block the hormone receptors of cancer cells, thus preventing androgens from stimulating growth.

Question 20

What are palliative treatment for prostate cancer?

Answer 20

Hormone treatment through androgen withdrawal or androgen blockade
Strontium-89 therapy - Radioactive isotope used for men with hormone relapsed prostate cancer and painful bone metastases. Delivered by IV and can be used as adjunctive treatment.
Radium-223 therapy - Radiopharmaceutical agent designed to deliver alpha radiation to bone metastases without affecting normal bone marrow. Appropriate for hormone relapsed prostate cancer and symptomatic bone metastases. Delivered by IV for 6 weeks.
Chemotherapy - includes Docetaxel, cabazitaxel and corticosteroids. Appropriate for hormone relapsed metastatic disease.
Bisphosphonates - for men taking androgen deprivation therapy who have osteoporosis or for pain relief in men with hormone refractory prostate cancer when other treatment has failed.

Question 21

What is the Gleason score for prostate cancer?

Answer 21

10-12 cores will be taken from the prostate gland
The most common and second most common patterns are analysed and graded into risk categories LOW (6 or less), INTERMEDIATE (7), HIGH (8 to 10)
The Gleason score is the sum of these two grades and can range from 2 to 10.

Question 22

What is the treatment for localised prostate cancer?

Answer 22

Low risk: Watchful waiting, radical prostatectomy or radical radiotherapy
Intermediate risk: Radical prostatectomy or radical radiotherapy with 6 months of androgen deprivation therapy. Other treatments that can be considered include watchful waiting, active surveillance or high dose rate brachytherapy in combination with EBR.
High risk: Radical prostatectomy or radical radiotherapy with 6 months of androgen deprivation therapy. Androgen deprivation therapy may be continued for up to 3 years.

Question 23

When would you refer for suspected prostate cancer?

Answer 23

Consider a PSA test or DRE in men with LUTS, erectile dysfunction or hematuria
Refer if the prostate feels malignant on DRE
Refer for an appointment within 2 weeks if PSA is high

Question 24

When would you refer for suspected bladder cancer?

Answer 24

Refer if if they are over 45 and have unexplained visible haematuria without UTIs or visible haematuria that persists following a UTI
Refer if they are over 60 and have unexplained non visible hematuria and
either dysuria or a raised white cell count on a blood test.
Refer if they are over 60 with recurrent or persistent unexplained UTIs

Question 25

When would you refer for suspected renal cancer?

Answer 25

Refer if they are over 45 and have unexplained visible haematuria without UTI or with visible hematuria that persists following a UTI

Question 26

When would you refer for suspected penile cancer?

Answer 26

Refer if the patient has a penile mass or ulcerated lesion, where a STI has been excluded as a cause
Refer if the patient has a persistent penile lesion after treatment for a STI has been
completed
Refer if the patient has unexplained or persistent symptoms affecting the foreskin or glands

Question 27

What are the two types of haematuria?

Answer 27

Two types of haematuria:
Visible (gross) – visibly discoloured urine. May present as red to brown or frank blood.
Invisible (microscopic) - ≤3 RBC/hpf in 2 or 3 urine specimens.

Question 28

What can cause haematuria?

Answer 28

Can be caused by
Infection (UTIs, pyelonephritis, genitourinary TB)
Malignancy (urothelial, renal cell, prostate, penile, squamous cell carcinomas and adenocarcinomas)
Penetrating or blunt trauma
Urinary stones
Structural abnormalities (BPH, cystic renal lesions, vascular malformations, renal vein thrombosis)
Kidney disease (benign familial haematuria, alport syndrome, glomerulonephritis, glomerular pathology)
Haematological disorders (sickle cell anaemia, coagulopathies, patients on anticoagulants)
Gynaecological (placenta percreta, endometriosis)
Iatrogenic (endoscopes, catheters, external beam radiation, prostate brachytherapy, cyclophosphamide, anticoagulation)
Idiopathic (exercise-induced haematuria, loin pain haematuria syndrome)
Pseudohematuria (certain medicines and food)

Question 29

Where can haematuria orignate from?

Answer 29

Can originate from any part of the urinary system - upper tract (kidneys and ureters) or lower tract (bladder and urethra)

Question 30

What investigations would you do if a patient presented with haematuria?

Answer 30

• Urine test strip analysis: heavy proteinuria indicates glomerulonephritis and presence of nitrites or leukocyte esterase indicates infection.
• Microscopic evaluation: confirms presence of RBCs, 3+ RBCs/hpf indicates ‘non-visible, ‘frank’ is usually >150 RBC/hpf,
  RBCs = tubular/glomerular source of bleeding
  Bacteria, WBCs and white cell casts = UTI
  Crystals = urolithiasis.
• Urine cultures for UTI.
• Urine cytology for urothelial carcinoma.
• FBCs: to assess anemia, leukocytosis = infection
  Serum creatinine and EGFR: evaluate renal function
• HB electrophoresis: diagnose sickle cell disease, measurement of the serum complement. Low serum complement levels indicate post infectious glomerulonephritis, SLE nephritis, bacterial endocarditis and membranoproliferative glomerulonephritis.
• High antistreptolysin O titre indicates a recent strep infection.
• PSA: assessing lower urinary tract e.g. prostate cancer
• Imaging: CTU is imaging modality of choice, MRU (magnetic resonance urography), non contrast CT scan or renal ultrasound with retrograde pyelography
• Cystoscopy – rigid or flexible cystoscope used to evaluate urothelium of bladder, prostate and urethra.
• Renal biopsy may be necessary to determine medical renal cause of visible.

Question 31

What are ureteric stones?

Answer 31

Stones (calculi) are hard masses that form in the urinary tract when normally soluble material, e.g. calcium, super saturates the urine and begins the process of crystal formation. Depending on where a stone is located, it may be called a kidney stone, ureteral stone, or bladder stone.

Question 32

What are the predisposing factors for ureteric stones?

Answer 32

Particular foods in your diet, seasonal factors, dehydration, diuretics, antacids, corticosteroids, aspirin, allopurinol, vitamin C, recurrent UTIs, metabolic abnormalities, urinary tract abnormalities, foreign bodies, family history.

Question 33

What are the different types of ureteric stones?

Answer 33

Calcium oxalate (75%): too much calcium in the urine
Magnesium ammonium phosphate/struvite (15%): usually caused by an infection
Urate (5%): too much uric acid in the urine
Cystine (1%): caused by an inherited condition called cystinuria

Question 34

What are the general symptoms of ureteric stones?

Answer 34

Asymptomatic or pain (excruciating spasms of renal colic ‘loin to groin’), nausea/vomiting, high temperature, urine infection, haematuria, proteinuria, sterile pyuria, anuria.

Question 35

What are the location-specific symptoms of ureteric stones?

Answer 35

Obstruction of :

• Kidneys (loin), of mid-ureter (may mimic appendicitis/diverticulitis
• Lower-ureter (bladder irritability, pain in the scrotum, penile tip, labia majora
• Bladder/urethra (pelvic pain, dysuria, interrupted flow).

Question 36

What are the investigations for ureteric stones?

Answer 36

Blood tests (FBC, U&Es, Ca, PO4, glucose, bicarbonate, urate), urine dipstick, kidney stones analysis, imaging: Non-contrast CT is investigation of choice

Question 37

What is the minor treatment for ureteric stones?

Answer 37

Stones <5mm in lower ureter - 90-95% pass spontaneously
Stones >5mm/pain is not resolving - nifedipine or a blockers to promote expulsion, analgesia, antibiotics and antiemetics if needed.

Question 38

What is the major treatment for ureteric stones?

Answer 38

Extracorporeal shock wave lithotripsy (ESWL) - uses high-energy shock waves to break down the kidney stones
Ureteroscopy - ureteroscope sent with a tiny wire basket into the lower ureter via the bladder, grabs the stone and pulls the stone free, with or without a stent.
Percutaneous nephrolithotomy (PCNL) - scope is inserted through a small incision in your back to remove the kidney stones, can be broken up or removed whole.
Open surgery - removes very large stones or stones that cannot be removed

Question 39

What are the preventative measures for ureteric stones?

Answer 39

Stay hydrated
Reduce the amount of oxalates in your diet
Reducing the intake of meat, poultry and fish
Review medication.

Question 40

What are UTIs?

Answer 40

Infection affecting different parts of your urinary tract, including your bladder (cystitis), urethra (urethritis) or kidneys (kidney infection).

Question 41

What are the symptoms of UTIs?

Answer 41

Dysuria, frequency, urgency, changes in urine appearance or consistency, nocturia, suprapubic discomfort/tenderness.

Question 42

How to treat a man with recurrent UTIs?

Answer 42

Treat each episode as for an acute lower UTI
Advise the man about behavioural and personal hygiene measures and self care treatments like ensuring good hydration and not delaying urination
Seek specialist advice
Consider a trial of daily antibiotic prophylaxis
Refer urgently using a suspected cancer pathway referral for an appointment within 2 weeks if a urological cancer is suspected.
Consider non urgent referral for bladder cancer in men aged 60 years and over with recurrent or persistent unexplained UTI.

Question 43

How to treat a woman with recurrent UTIs?

Answer 43

Manage acute UTIs
Seek specialist advice if the cause is unknown or there is suspected malignancy
Discuss behavioural and personal hygiene measures
- Avoid douching and occlusive underwear
- Wipe from front to back after defecation
- Avoid delay of habitual and post-coital urination
Maintain adequate hydration
Consider prescribing vaginal oestrogen in postmenapausal, reviewed within 12 months.
Consider antibiotic prophylaxis

Question 44

What is the Antibiotic prophylaxis for recurrent UTIs?

Answer 44

First-line
Trimethoprim 200mg single dose when exposed to a trigger, or 100mg a night.
Nitrofurantoin (if eGFR more than or equal to 45ml/minute) 100mg single dose when exposed to a trigger or 50 – 100 mg at night.
Second-line
Amoxicillin 500mg single dose when exposed to a trigger or 250mg at night (off label use).
Cefalexin 500mg single dose when exposed to a trigger, or 125mg at night.
Review every 6 months.

Question 45

What is urinary incontinence?

Answer 45

Unintentional passing of urine

Question 46

What are the types of urinary incontinence?

Answer 46

Stress incontinence – when urine leaks out at times when your bladder is under pressure; for example, when you cough or laugh
Urge incontinence – when urine leaks as you feel a sudden, intense urge to pee, or soon afterwards
Overflow incontinence (chronic urinary retention) – when you’re unable to fully empty your bladder, which causes frequent leaking
Total incontinence – when your bladder cannot store any urine at all, which causes you to pass urine constantly or have frequent leaking
Mixed incontinence - symptoms of both stress and urge incontinence

Question 47

What are the potential causes of urinary incontinence?

Answer 47

Stress incontinence - damage to urethra sphincter or pelvic floor muscles due to childbirth, pregnancy, obesity, surgical damage, Parkinson’s, MS, Ehlers-Danlos syndrome, certain medications.
Urge incontinence - problems with detrusor muscles caused by too much alcohol, dehydration, constipation, UTIs, tumours, neurological conditions, certain medicines.
Overflow incontinence - obstruction of the bladder caused by enlarged prostate gland, bladder stones, constipation or nerve of medication-related problems with the detrusor muscles.
Total incontinence - problems with the bladder from birth, injury to the spinal cord, a bladder fistula.

Question 48

Which medications can cause urinary incontinence?

Answer 48

Angiotensin converting enzyme (ACE) inhibitors, diuretics, some antidepressants, hormone replacement therapy (HRT), sedatives.

Question 49

What are the risk factors of urinary incontinence?

Answer 49

Family history, increasing age, LUTS

Question 50

What are the investigations you would perform if a patient presented with urinary incontinence?

Answer 50

Bladder diary, physical examinations, urine dipstick, residual urine test (catheter or ultrasound), cystoscopy, urodynamic tests,

Question 51

How would you treat general urinary incontinence non-pharmacologically?

Answer 51

Lifestyle changes: reducing caffeine, drinking an appropriate amount, losing weight
Pelvic floor muscle training: 8 muscle contractions at least 3 times a day and last for at least 3 months
Electrical stimulation: electric current to help strengthen pelvic floor muscles
Biofeedback: probes or electrodes used to monitor how well the patient is doing their pelvic floor exercises
Vaginal cones to build up pelvic floor muscle strength
Bladder training: to increase the length of time between feeling the need to urinate and passing urine
Incontinence products: pants/pads, handheld urinals, catheters

Question 52

How would you treat general urinary incontinence pharmacologically?

Answer 52

Medicines: duloxetine (stress incontinence), antimuscarinics or mirabegron (urge incontinence), desmopressin or loop diuretics (nocturia).

Question 53

What are the specific treatments for stress incontinence?

Answer 53

Open or laparoscopic colposuspension: cut in your lower abdomen, lifting the neck of the bladder, and stitching it in this lifted position.
Sling surgery: sling around the neck of the bladder (female) and around part of the urethral bulb (male). Can be autologous, allograft or xenograft.
Urethral bulking agents: substance that’s injected into the walls of the urethra in females with stress incontinence.
Artificial urinary sphincter: a circular cuff that’s placed around the urethra, a small pump placed in the scrotum and a small fluid-filled reservoir in the abdomen.

Question 54

What are the specific treatments for urge incontinence?

Answer 54

Botulinum toxin A injections: Effective for urge incontinence.

• Sacral nerve stimulation: device is inserted near 1 of your sacral nerves, usually in 1 of your buttocks. An electrical current is sent from the device into the sacral nerve.
• Posterior tibial nerve stimulation: 12 sessions of stimulation whereby a thin needle is inserted through the skin of the ankle and a mild electric current is sent through it.
• Augmentation cystoplasty: making the bladder bigger by adding a piece of tissue from the intestine into the bladder wall.
• Urinary diversion: ureters are redirected to the outside of the body.
• Catheterisation for overflow incontinence: clean intermittent catheterisation (CIC) is used to empty the bladder at regular intervals or an indwelling catheter can be used which stays in place.